All That Bleeds in Cirrhoticʼs Is Not Variceal

Abstract

Purpose: Although the most common cause of upper gastrointestinal (UGI) bleeding in cirrhotic patients is related to complications of portal hypertension, all cases may not be variceal in nature. We are presenting here an unusual cause of esophageal bleeding in a patient with prior history of cirrhosis and variceal bleeding. Case: A 53 year old male patient with underlying alcoholic cirrhosis presented with 1 day history of hematemesis and melena. Vitals on presentation were: blood pressure 143/84, pulse of 142. Physical examination was remarkable for peripheral stigmata of alcoholic liver disease and ascites. Early endoscopic examination revealed grade I non bleeding esophageal varices and a mucosal defect/prominence seen in the distal esophagus. Gastric examination revealed moderate portal hypertensive gastropathy. On withdrawal of the endoscope active arterial spurting was seen in the distal esophagus (at the site of the mucosal defect). Injection treatment and electrocautery were used to slow down the rate of bleeding, but complete hemostasis could not be achieved. The patient underwent exploratory laprotomy and intra operative esophagogastroduodenoscopy, which confirmed the diagnosis of esophageal Dieulafoy's lesion as the cause of bleeding. Oversewing of the esophageal vessel and ligation of the first branch of the left gastric artery was performed, which resulted in hemostasis of this arterial lesion. Discussion: Dieulafoy's lesion is a rare arterial malformation that can cause massive GI hemorrhage. The lesion occurs most commonly in the proximal stomach. The esophagus is not a common location for this lesion. While evaluating cirrhotic patient's with UGI bleeding physicians must consider other sources like mallory weiss, peptic ulcer disease and Dieulafoy's lesion. Endoscopic diagnosis of Dieulafoy's lesion can be difficult because of the small size and obscure location of the lesion. Awareness of the condition and early correct diagnosis are extremely important for good outcomes. The treatment may require multi modality approach including timely surgical intervention.